KPCO Commercial HMO Drug Exclusion List Page 1 of 17

Revision date: November 2021

The following is a list of drugs and drug entities that are excluded from prescription benefit

coverage. Prior authorization will not apply. Kasier Permanente reserves the right to exclude

any drug at any time from the Kaiser Permanente Colorado Formulary for health and safety

concerns or other reasons as determined by Kaiser Permanente at its discretion.

If you have questions about the formulary status of a medication, or your prescription benefits,

please call our Member Services (see number on your ID Card).

This list is subject to change at any time.

EXCLUSION CRITERIA

• Drugs and supplies for cosmetic purposes

• Drugs for the promotion, prevention, or other treatment of hair loss or growth

• Drugs related to non-covered services

• Drugs to enhance athletic performance

• Drugs to shorten the duration of the common cold

• Drugs to treat infertility*

• Drugs to treat sexual dysfunction*

• Drugs used in the treatment of weight management*

• Medical supplies such as dressings and antiseptics

• Nonprescription drugs, unless otherwise noted

• Packaging of drugs other than the dispensing pharmacy’s standard packaging

• Prescription drugs for which there is a nonprescription equivalent available, unless

otherwise noted

Kaiser Permanente Commercial HMO Drug Exclusion

KPCO Commercial HMO Drug Exclusion List Page 2 of 17

Revision date: November 2021

• Prescriptions filled at a non-plan pharmacy, except for emergencies as described in

your EOC

• Replacement of lost, stolen, or damaged prescription drugs and/or devices

• Vaccines (usually covered under medical)

• Vitamins and nutritional supplements that can be purchased without a prescription

• Medical service drugs

• Any drug being used for a non-approved indication

• Medical foods and medical devices

*Drug Category is excluded unless your plan has a buy-up for that benefit

(1)(2)(3) Drug Category is excluded unless your plan has a buy-up for that benefit (1) Infertility Drug Category; (2) Sexual Dysfunction Drug Category; (3) Weight Loss Drug Category

KPCO Commercial HMO Drug Exclusion List Page 3 of 17

Revision date: November 2021

Kaiser Permanente Commercial HMO Drug Exclusion List Listed are items that are excluded from prescription benefit coverage.

All of the excluded drug entities, strengths, formulations &/or package sizes may not be listed. The list is not all inclusive and is subject to change.

Office administered drugs and IV drugs are covered under the Medical benefit and excluded from being dispensed from retail pharmacy

EXCLUDED DRUGS 1ST GENERATION ANTIHISTAMINE-DECONGESTANT-ANALGESIC COMBINATIONS (ORAL) 1ST GENERATION ANTIHISTAMINE-DECONGESTANT-ANALGESIC, SALICYLATE (ORAL) 1ST GENERATION ANTIHISTAMINE-DECONGESTANT-ANALGESIC-EXPECTORANT COMBINATIONS (ORAL) 1ST GENERATION ANTIHISTAMINE-DECONGESTANT-EXPECTORANT COMBINATIONS (ORAL) 1ST GENERATION ANTIHISTAMINE-DECONGESTANT-NSAID, COX NONSPECIFIC (ORAL) 2'-FUCOSYLLACTOSE, LACTO-N-NEOTETRAOSE (ORAL) 2ND GENERATION ANTIHISTAMINE (ORAL) 2ND GENERATION ANTIHISTAMINE-DECONGESTANT (ORAL) ACANYA GEL (TOPICAL)

ACETAMINOPHEN-GUAIFENESIN (ORAL)

ACETIC ACID (IRRIGATION)

ACIPHEX

ACRIVASTINE & PSEUDOEPHEDRINE (ORAL)

ACTIVE-PAC/GABAPENTIN THPK (PACK)

ACYCLOVIR-HYDROCORTISONE (TOPICAL)

ACYCLOVIX THPK (TOPICAL)

ADASUVE (INH)

ADDYI (ORAL) (2)

AKYNZEO (ORAL)

ALLEGRA (ORAL)

EXCLUDED DRUGS

ALLEGRA-D (ORAL)

ALPROSTADIL (INJ) (2) ANALGESIC, NON-SALICYLATE-1ST GENERATION ANTIHISTAMINE (ORAL) ANALGESIC, NON-SALICYLATE-EXPECTORANT COMBINATIONS (ORAL) ANALGESICS, MIXED-1ST GENERATION ANTIHISTAMINE (ORAL) ANNOVERA RING

ANTITUSSIVES, NON-NARCOTIC (ORAL)

APLENZIN (ORAL)

APPTRIM (ORAL)

APPTRIM-D (ORAL)

ARIPIPRAZOLE LAUROXIL (INJ)

AVAILNEX (ORAL)

AXONA (ORAL)

AZELEX CREAM

BENZPHETAMINE HCL (ORAL) (3)

BESER KIT (EXTERNAL) BETAMETHASONE SOD PHOSPHATE & ACETATE (KIT) BETAQUIK (ORAL)

BIMATOPROST (TOPICAL)

BOTOX COSMETIC (INJ) BROMPHENIRAMINE-ACETAMINOPHEN (ORAL) BULK PRODUCTS *

BUPRENORPHINE HCL (KIT)

Kaiser Permanente Commercial HMO Drug Exclusion List Listed are items that are excluded from prescription benefit coverage.

All of the excluded drug entities, strengths, formulations &/or package sizes may not be listed. The list is not all inclusive and is subject to change.

Office administered drugs and IV drugs are covered under the Medical benefit and excluded from being dispensed from retail pharmacy.

(1)(2)(3) Drug Category is excluded unless your plan has a buy-up for that benefit (1) Infertility Drug Category; (2) Sexual Dysfunction Drug Category; (3) Weight Loss Drug Category

KPCO Commercial HMO Drug Exclusion List Page 4 of 17

Revision date: November 2021

EXCLUDED DRUGS BUTALBITAL-ACETAMINOPHEN CAPS 50-300 MG CABENUVA (INJ)

CAMPHOR (INH)

CAMPHOR-EUCALYPTUS-MENTHOL (INH)

CAPXIB (KIT)

CARDIOTEK RX (ORAL)

CARISOPRODOL (ORAL) CARISOPRODOL W/ ASPIRIN & CODEINE (ORAL) CARISOPRODOL W/ ASPIRIN (ORAL)

CATHETERS (DEVICE)

CAVERJECT (INJ) (2)

CELECOXIB-CAPSAICIN-MENTHOL (KIT)

CETIRIZINE HCL (ORAL)

CETRORELIX ACETATE (KIT) (1) CHLORHEXIDINE GLUCONATE-MUPIROCIN-DIMETHICONE-SILICONE (KIT) CHLORPHENIRAMINE-ACETAMINOPHEN (ORAL) CHLORPHENIRAMINE-PHENYLEPHRINE-ACETAMINOPHEN (ORAL) CHLORPHENIRAMINE-PHENYLEPHRINE-ASPIRIN (ORAL) CHLORPHENIRAMINE-PHENYLEPHRINE-IBUPROFEN (ORAL) CHLORPHENIRAMINE-PSEUDOEPHEDRINE-IBUPROFEN (ORAL) CHORIOGONADOTROPIN ALFA (INJ) (1)

CHORIONIC GONADOTROPIN (INJ) (1)

EXCLUDED DRUGS

CIALIS (ORAL) (2)

CICLOPIROX (KIT)

CICLOPIROX-UREA (PACK)

CIMETIDINE (TABS)

CLIN SINGLE USE (KIT)

CLINDACIN (KIT) CLINDAMYCIN PHOSPHATE-BENZOYL PEROXIDE & MOISTURIZER (KIT) CLINDAMYCIN PHOSPHATE-TRETINOIN (TOPICAL) CLINDAREACH (KIT)

CLINDAVIX KIT

CLM PTCH

CLOBETAVIX KIT

CLOBETEX THPK

CLODAN KIT (TOP)

CLOMIPHENE CITRATE (ORAL) (1)

CONSENSI (ORAL) CONTINUOUS BLOOD GLUCOSE SYSTEM/DEVICE COSMETIC PRODUCTS * COUGH AND/OR COLD PREPARATIONS (ORAL) CRYSVITA SOLN

CYANOCOBALAMIN (KIT)

CYCLOBENZAPRINE HCL W/ LINIMENT (KIT) CYCLOBENZAPRINE-CAPSAICIN-MENTHOL (PACK)

Kaiser Permanente Commercial HMO Drug Exclusion List Listed are items that are excluded from prescription benefit coverage.

All of the excluded drug entities, strengths, formulations &/or package sizes may not be listed. The list is not all inclusive and is subject to change.

Office administered drugs and IV drugs are covered under the Medical benefit and excluded from being dispensed from retail pharmacy.

(1)(2)(3) Drug Category is excluded unless your plan has a buy-up for that benefit (1) Infertility Drug Category; (2) Sexual Dysfunction Drug Category; (3) Weight Loss Drug Category

KPCO Commercial HMO Drug Exclusion List Page 5 of 17

Revision date: November 2021

EXCLUDED DRUGS

CYCLOPAK THPK (KIT)

DARZALEX FASPRO DECONGESTANT-ANALGESIC, NON-SALICYLATE COMBINATIONS (ORAL) DECONGESTANT-ANALGESIC-EXPECTORANT COMBINATIONS (ORAL) DECONGESTANT-EXPECTORANT COMBINATIONS (ORAL) DECONGESTANT-NSAID, COX NON-SPECIFIC COMBINATIONS (ORAL) DEPLIN (ORAL)

DERMACINRX LIDOGEL

DERMACINRX SILAPAK (KIT)

DERMACINRX TICANASE (NASAL)

DERMAPAK PAK PLUS (TOPICAL)

DERMASORB HC (KIT)

DERMASORB TA (KIT)

DESLORATADINE (ORAL)

DESLORATADINE-PSEUDOEPHEDRINE (ORAL) DEXBROMPHENIRAMINE-ACETAMINOPHEN (ORAL) DEXBROMPHENIRAMINE-PHENYLEPHRINE-ACETAMINOPHEN (ORAL) DEXILANT (ORAL)

DEXLIDO (KIT)

DEXLIDO-M (KIT)

DEXTROMETHORPHAN (ORAL)

DEXTROMETHORPHAN-BENZOCAINE (ORAL)

EXCLUDED DRUGS DEXTROMETHORPHAN-BENZOCAINE-MENTHOL (ORAL) DEXTROMETHORPHAN-MENTHOL (ORAL)

DICLOFENAC EPOLAMINE (PATCH) DICLOFENAC SODIUM & ADHESIVE SHEETS (PACK) DICLOFENAC SODIUM & OCCLUSIVE DRESSING (TOPICAL) DICLOFENAC SODIUM & RANITIDINE HCL & LIDOCAINE-PRILOCAINE (PACK) DICLOFENAC SODIUM (KIT) DICLOFENAC SODIUM-BENZALKONIUM CHLORIDE (PACK) DICLOFENAC SODIUM-CAMPHOR-MENTHOL-METHYL SALICYLATE (KIT) DICLOFENAC SODIUM-CAPSAICIN (PACK)

DICLOFENAC SODIUM-CAPSAICIN (TOPICAL) DICLOFENAC SODIUM-RANITIDINE HCL-CAPSAICIN (PACK) DICLOFENAC SODIUM-RANITIDINE HCL-LIDOCAINE (PACK) DICLOFENAC SODIUM SOLN

DICLOTREX

DICLOVIX KIT

DICLOVIX M THPK

DIETARY MANAGEMENT PRODUCTS *

DIETHYLPROPION HCL (ORAL)

DIFFERIN CREAM 0.1 %

DIFFERIN GEL 0.1 %

DIHYDROXYACETONE (TOPICAL)

Kaiser Permanente Commercial HMO Drug Exclusion List Listed are items that are excluded from prescription benefit coverage.

All of the excluded drug entities, strengths, formulations &/or package sizes may not be listed. The list is not all inclusive and is subject to change.

Office administered drugs and IV drugs are covered under the Medical benefit and excluded from being dispensed from retail pharmacy.

(1)(2)(3) Drug Category is excluded unless your plan has a buy-up for that benefit (1) Infertility Drug Category; (2) Sexual Dysfunction Drug Category; (3) Weight Loss Drug Category

KPCO Commercial HMO Drug Exclusion List Page 6 of 17

Revision date: November 2021

EXCLUDED DRUGS

DIMENTHO THPK

DIPHENHYDRAMINE-ACETAMINOPHEN (ORAL) DIPHENHYDRAMINE-PHENYLEPHRINE-ACETAMINOPHEN (ORAL) DITHOL THPK (PACK)

DMT SUIK (KIT)

DNA COLLECTION PRODUCT (KIT)

DOLOTRANZ (KIT)

DOUBLEDEX (KIT)

DOXYCYCLINE HYCLATE W/ CLEANSER (KIT) DOXYLAMINE-PHENYLEPHRINE-ACETAMINOPHEN (ORAL) DROXICIN LIQUID

DSUVIA (ORAL)

DUROLANE (INJ)

DUEXIS (ORAL)

DURYSTA IMPL

DYMISTA SUSP (NASAL SPRAY)

ECONASIL KIT

EDEX (INJ) (2)

ELFOLATE (ORAL)

ELIGEN B12 (ORAL)

ELLZIA PAK (TOPICAL)

EMEND SUSP (ORAL)

EMOLLIENT-SKIN MOISTURIZERS (TOPICAL)

ENLYTE (ORAL)

EXCLUDED DRUGS

ENTERAGAM (ORAL)

ENTERAL NUTRITION (SUPPLIES)

ENTEREG (ORAL)

EPHEDRINE-GUAIFENESIN (ORAL)

EPICERAM EMUL (TOP)

ESKATA SOLN (TOPICAL)

ESOMEP-EZS KIT

ESOMEPRAZOLE MAGNESIUM (ORAL)

EUFLEXXA (INJ)

EVENITY (INJ)

EXPECTORANTS (ORAL)

EXPECTORANTS, COMBINATIONS (ORAL) FAMOTIDINE (ORAL; Not including 40mg /5 ml SUSP) FASENRA (INJ)

FEEDING TUBES/SETS (DEVICE)

FENSOLVI KIT

FERREX 150 FORTE PLUS (ORAL)

FEXOFENADINE HCL (ORAL)

FEXOFENADINE-PSEUDOEPHEDRINE (ORAL)

FIBER-STAT (ORAL)

FINACEA FOAM

FINACEA GEL

FINASTERIDE (ALOPECIA) (ORAL)

FIRST-BACLOFEN SUSPENSION (ORAL)

Kaiser Permanente Commercial HMO Drug Exclusion List Listed are items that are excluded from prescription benefit coverage.

All of the excluded drug entities, strengths, formulations &/or package sizes may not be listed. The list is not all inclusive and is subject to change.

Office administered drugs and IV drugs are covered under the Medical benefit and excluded from being dispensed from retail pharmacy.

(1)(2)(3) Drug Category is excluded unless your plan has a buy-up for that benefit (1) Infertility Drug Category; (2) Sexual Dysfunction Drug Category; (3) Weight Loss Drug Category

KPCO Commercial HMO Drug Exclusion List Page 7 of 17

Revision date: November 2021

EXCLUDED DRUGS

FIRST-BXN MOUTHWASH

FIRST-HYDROCORTISONE GEL (TOPICAL)

FIRST-LANSOPRAZOLE SUSP (ORAL)

FIRST-MARYS MOUTHWASH

FIRST-METRONIDAZOLE SUSPENSION (ORAL)

FIRST-MOUTHWASH BLM

FIRST-OMEPRAZOLE SUSP (ORAL)

FIRST-PROGESTERONE VGS (SUPPOSITORY)

FIRST-TESTOSTERONE (TOPICAL)

FIRST-VANCOMYCIN SOLN (ORAL)

FLECTOR PATCH (TOPICAL)

FLUOPAR KIT

FLUOVIX (TOPICAL)

FOLBIC (ORAL) FOLIC ACID-CYANOCOBALMIN-PYRIDOXINE (ORAL) FOLLITROPIN ALFA (INJ) (1)

FOLLITROPIN BETA (INJ) (1)

FORFIVO XL (ORAL)

FORTAMET (ORAL)

FOSTEUM (ORAL)

FOSTEUM PLUS (ORAL)

FOVEX (ORAL)

GABACAINE THPK

GABADONE (ORAL)

EXCLUDED DRUGS

GABAPAL THPK

GANIRELIX ACETATE (INJ) (1)

GELNIQUE GEL (TOPICAL)

GEL-ONE (INJ)

GELSYN (INJ)

GENVISC (INJ)

GIVLAARI SOLN (INJ)

GLIADEL WAFER (IMPLANT)

GLUMETZA (ORAL)

GLYXAMBI (ORAL)

GOSERELIN ACETATE (IMPLANT)

GUAIFENESIN (ORAL)

HALAC (KIT)

HALONATE (KIT)

HALOPERIDOL DECANOATE (INJ)

HEMLIBRA (INJ) HEPATITIS B IMMUNE GLOBULIN (HUMAN) (INJ) HERCEPTIN HYLECTA SOLN (INJ)

HYALGAN (INJ)

HYDROQUINONE (TOPICAL)

HYDROQUINONE MICROSPHERES (TOPICAL)

HYDROQUINONE W/ SUNSCREENS (TOPICAL) HYDROXYPROGESTERONE CAPROATE (ANTINEOPLASTIC) (INJ) HYMOVIS (INJ)

Kaiser Permanente Commercial HMO Drug Exclusion List Listed are items that are excluded from prescription benefit coverage.

All of the excluded drug entities, strengths, formulations &/or package sizes may not be listed. The list is not all inclusive and is subject to change.

Office administered drugs and IV drugs are covered under the Medical benefit and excluded from being dispensed from retail pharmacy.

(1)(2)(3) Drug Category is excluded unless your plan has a buy-up for that benefit (1) Infertility Drug Category; (2) Sexual Dysfunction Drug Category; (3) Weight Loss Drug Category

KPCO Commercial HMO Drug Exclusion List Page 8 of 17

Revision date: November 2021

EXCLUDED DRUGS

HYPERTENSA (ORAL)

IBUPAK KIT

IBUPROFEN (OTC EQUIV) (ORAL)

IBUPROFEN W/ LINIMENT (KIT)

ILUMYA (INJ)

ILUVIEN IMPLANT

IMCIVREE SOLN (INJ)

IMMUNE GLOBULIN (HUMAN) (INJ)

IMPEKLO LOTION INCONTINENCE SUPPLIES/WOUND CARE DRAINAGE (SUPPLIES) INFERTILITY DRUGS (1)

INFLATHERM KIT

INHALER, SPACER/CHAMBER (DEVICE)

IN-OFFICE ADMINISTERED PRODUCTS *

INTRAROSA (VAG)

INTRAROSA INST (VAG)

INTRA-UTERINE DEVICES (IUDS)

INTRAVENOUS INJECTIONS *

INVEGA HAFYERA (INJ)

INVEGA SUSTENNA SUSP (INJ)

INVEGA TRINZA SUSP (INJ)

INVOKAMET IR & XR (ORAL)

ISOVACTIN AA PLUS BERRY (ORAL)

IV CATHETER (SUPPLIES)

EXCLUDED DRUGS

IV SETS/TUBING (SUPPLIES)

JANUMET IR & XR (ORAL)

JENTADUETO IR & XR (ORAL)

KARAYA GUM (TOPICAL)

KAZANO (ORAL)

KELARX GEL

KETOCAL 3:1 POWDER (ORAL)

KETOCAL 4:1 LQ (ORAL)

KETOCAL 4:1 POWDER (ORAL)

KETOCONAZOLE & CLEANSER (KIT)

KETODAN (KIT)

KETOROCAINE-L (KIT)

KETOROCAINE-LM (KIT)

KETOROLAC TROMETHAMINE (INJ)

KETOTIFEN FUMARATE (OPHTH)

KETOVIE 4:1 (ORAL)

KETOVIE PEPTIDE (ORAL)

KOMBIGLYZE XR (ORAL)

LANSOPRAZOLE (OTC EQUIV) (ORAL)

LATISSE SOLN 0.03 %

LETROZOLE (ORAL) (1) LEUPROLIDE ACETATE & NORETHINDRONE ACETATE (KIT) LEUPROLIDE ACETATE (INJ)

LEVITRA (ORAL) (2)

Kaiser Permanente Commercial HMO Drug Exclusion List Listed are items that are excluded from prescription benefit coverage.

All of the excluded drug entities, strengths, formulations &/or package sizes may not be listed. The list is not all inclusive and is subject to change.

Office administered drugs and IV drugs are covered under the Medical benefit and excluded from being dispensed from retail pharmacy.

(1)(2)(3) Drug Category is excluded unless your plan has a buy-up for that benefit (1) Infertility Drug Category; (2) Sexual Dysfunction Drug Category; (3) Weight Loss Drug Category

KPCO Commercial HMO Drug Exclusion List Page 9 of 17

Revision date: November 2021

EXCLUDED DRUGS

LEVOCETIRIZINE DIHYDROCHLORIDE (ORAL) LEVONORGESTREL (EMERGENCY OC) OTC (ORAL) LEVONORGESTREL IUD (DEVICE)

LICART

LIDOCAINE PATCH 5 % LIDOCAINE-PENTAFLUOROPROP-TETRAFLUOROETH-ULTRASOUND (KIT) LIDOCAINE-PRILOCAINE (KIT) LIDOCAINE-PRILOCAINE-MENTHOL-METHYL SALICYLATE (KIT) LIDOCAINE-PRILOCAINE-SODIUM CHLORIDE (KIT) LIDOCAINE-TRANSPARENT DRESSING (KIT)

LIDOMARK (KIT)

LIDOPAC (KIT)

LIDOPURE PATCH (KIT)

LIDOTIN THPK

LIDOVIX KIT

LIFEMS NALOXONE PSKT

LIMBREL (ORAL)

LIPISTART (ORAL)

LIPRITIN THPK

LIQUIGEN (ORAL)

LIRAGLUTIDE (WEIGHT MANAGEMENT) (INJ)

LISTER-V (ORAL)

LMR PLUS KIT

EXCLUDED DRUGS

LOPROX KIT

LORCASERIN HCL (ORAL)

LORVATUS PHARMAPAK (KIT)

LOXAPINE (INH)

LUKAID GLA (ORAL)

LUNGLAID (ORAL)

MACI SHEET

MAKENA (INJ)

MARDEX-25 (KIT)

MCT OIL (ORAL)

MECLIZINE HCL (ORAL) MEDROXYPROGESTERONE ACETATE SUSP (INJ) MELOXICAM W/ LINIMENT (KIT)

MEMANTINE HCL-DONEPEZIL HCL (ORAL)

MENOTROPINS (INJ) (1)

MENTHOL (MOUTH-THROAT) (ORAL)

MIACALCIN (INJ)

MICONAZOLE NITRATE (VAG)

MICROVIX KIT

MINOXIDIL (TOPICAL)

MIRVASO GEL (TOPICAL) MISC NATURAL WEIGHTLOSS PRODUCTS (ORAL) MONOBENZONE (TOPICAL)

MONOGEN (ORAL)

Kaiser Permanente Commercial HMO Drug Exclusion List Listed are items that are excluded from prescription benefit coverage.

All of the excluded drug entities, strengths, formulations &/or package sizes may not be listed. The list is not all inclusive and is subject to change.

Office administered drugs and IV drugs are covered under the Medical benefit and excluded from being dispensed from retail pharmacy.

(1)(2)(3) Drug Category is excluded unless your plan has a buy-up for that benefit (1) Infertility Drug Category; (2) Sexual Dysfunction Drug Category; (3) Weight Loss Drug Category

KPCO Commercial HMO Drug Exclusion List Page 10 of 17

Revision date: November 2021

EXCLUDED DRUGS

MONOVISC (INJ)

MUGARD (ORAL) MULTIPLE VITAMINS W/ MINERALS & FOLIC ACID (ORAL) MUSE PELLETS (IMPLANT) (2)

NALTREXONE (INJ)

NALTREXONE HCL-BUPROPION HCL (ORAL)

NAMZARIC CP24 (ORAL)

NAPROPAK (PACK)

NAPROXEN SODIUM-MENTHOL (PACK)

NAPROXEN W/ LINIMENT (KIT)

NAPROXEN-CAPSAICIN-MENTHOL (KIT) NAPROXEN-ESOMEPRAZOLE MAGNESIUM (ORAL) NASAL ANTI-INFLAMMATORY STEROIDS (NASAL) NEOCATE JUNIOR (ORAL)

NEOCATE JUNIOR WITH PREBIOTICS (ORAL)

NEOCATE NUTRA (ORAL)

NEOCATE'S E028 SPLASH (ORAL)

NEO-SYNALAR (KIT)Bottom of Form

NEUAC (KIT)

NEUREMEDY (ORAL)

NEXIUM (ORAL)

NEXPLANON CONTRACEPTIVE IMPLANT

NICAZELDOXY 30 (KIT)

EXCLUDED DRUGS NIZATIDINE (ORAL; Not including Soln 15 mg/ 5 ml) NON-NARCOTIC ANTITUSSIVE-1ST GENERATION ANTIHISTAMINE COMBINATIONS (ORAL) NON-NARCOTIC ANTITUSSIVE-1ST GENERATION ANTIHISTAMINE-ANALGESIC COMBINATIONS (ORAL) NON-NARCOTIC ANTITUSSIVE-1ST GENERATION ANTIHISTAMINE-DECONGESTANT (ORAL) NON-NARCOTIC ANTITUSSIVE-1ST GENERATION ANTIHISTAMINE-DECONGESTANT-ANALGESIC COMBINATIONS (ORAL) NON-NARCOTIC ANTITUSSIVE-1ST GENERATION-DECONGESTANT-SALICYLATE (ORAL) NON-NARCOTIC ANTITUSSIVE-ANALGESIC COMBINATIONS (ORAL) NON-NARCOTIC ANTITUSSIVE-DECONGESTANT COMBINATIONS (ORAL) NON-NARCOTIC ANTITUSSIVE-DECONGESTANT-ANALGESIC COMBINATIONS (ORAL) NON-NARCOTIC ANTITUSSIVE-DECONGESTANT-ANALGESIC-EXPECTORANT COMBINATIONS (ORAL) NON-NARCOTIC ANTITUSSIVE-DECONGESTANT-EXPECTORANT COMBINATIONS (ORAL) NON-NARCOTIC ANTITUSSIVE-EXPECTORANT COMBINATIONS (ORAL) NOPIOID-TC KIT THPK

NORITATE (TOPICAL)

NOVOLIN 70-30 (INJ)

NOVOLIN N (INJ)

Kaiser Permanente Commercial HMO Drug Exclusion List Listed are items that are excluded from prescription benefit coverage.

All of the excluded drug entities, strengths, formulations &/or package sizes may not be listed. The list is not all inclusive and is subject to change.

Office administered drugs and IV drugs are covered under the Medical benefit and excluded from being dispensed from retail pharmacy.

(1)(2)(3) Drug Category is excluded unless your plan has a buy-up for that benefit (1) Infertility Drug Category; (2) Sexual Dysfunction Drug Category; (3) Weight Loss Drug Category

KPCO Commercial HMO Drug Exclusion List Page 11 of 17

Revision date: November 2021

EXCLUDED DRUGS

NOVOLIN R (INJ)

NUDROXICIN (TOPICAL)

NUDROXIPAK (KIT)

NUCALA INJ

NUCARACLINPAK KIT

NUCARARXPAK KIT

NUDERMRXPAK

NUVAKAAN (KIT)

NYSTATIN & EXFOLIATING AGENT (KIT)

OMEGA-3/D-3 WELLNESS (KIT)

OMEPRAZOLE-SODIUM BICARBONATE (ORAL)

ONEXTON GEL (TOPICAL)

ORAL SYRINGES (SUPPLIES)

ORAL WOUND CARE PRODUCTS (ORAL)

ORLISTAT (ORAL)

ORTHOVISC (INJ)

OSPHENA (ORAL) (2)

OTC PRODUCTS *

OXLUMO SOLN

OXYTROL PATCH

OSENI (ORAL)

OZURDEX OPTHALMIC (IMPLANT)

PAINGO KFT (KIT)

PALFORZIA INITIAL STARTER PACK

EXCLUDED DRUGS

PAPAVERINE (INJ) (2)

PAPAVERINE-ALPROSTADIL (INJ) (2)

PAPAVERINE-PHENTOLAMINE (INJ) (2) PAPAVERINE-PHENTOLAMINE-ALPROSTADIL (INJ) (2) PARENTERAL ADMINISTRATION SETS (SUPPLIES) PATADAY SOLN

PECTIN (MOUTH-THROAT) (ORAL)

PEDIADERM AF (KIT)

PEDIADERM HC (KIT)

PENNSAID SOLN

PENTICAN THPK

PERCURA (ORAL)

PERSERIS (INJ)

PHENAZOPYRIDINE HCL (ORAL)

PHENDIMETRAZINE TARTRATE (ORAL) (3) PHENIRAMINE-PHENYLEPHRINE-ACETAMINOPHEN (ORAL) PHENTERMINE HCL (ORAL) (3)

PHENTERMINE HCL-TOPIRAMATE (ORAL) (3)

PHENTOLAMINE MESYLATE (INJ) (2)

PHENTOLAMINE-ALPROSTADIL (INJ) (2)

PHENYLEPHRINE-ACETAMINOPHEN (ORAL) PHENYLEPHRINE-ACETAMINOPHEN-GUAIFENESIN (ORAL) PHENYLEPHRINE-DIPHENHYDRAMINE-GUAIFENESIN-ACETAMINOPHEN (ORAL)

Kaiser Permanente Commercial HMO Drug Exclusion List Listed are items that are excluded from prescription benefit coverage.

All of the excluded drug entities, strengths, formulations &/or package sizes may not be listed. The list is not all inclusive and is subject to change.

Office administered drugs and IV drugs are covered under the Medical benefit and excluded from being dispensed from retail pharmacy.

(1)(2)(3) Drug Category is excluded unless your plan has a buy-up for that benefit (1) Infertility Drug Category; (2) Sexual Dysfunction Drug Category; (3) Weight Loss Drug Category

KPCO Commercial HMO Drug Exclusion List Page 12 of 17

Revision date: November 2021

EXCLUDED DRUGS

PHENYLEPHRINE-GUAIFENESIN (ORAL)

PHENYLEPHRINE-IBUPROFEN (ORAL) PHENYLTOLOXAMINE-ACETAMINOPHEN (ORAL) PHESGO SOLN

PHEXXI GEL

PLAN B ONE-STEP (ORAL)

PLIXDA PADS (EXTERNAL)

PRASTERA (ORAL)

PRENATAL VITAMIN PREPARATIONS

PREVACID (ORAL)

PREVACID SOLUTAB

PREVIDENT (DENTAL)

PRILO PATCH KIT

PRIZOTRAL KIT

PROBARIMIN QT (ORAL)

PROBIOTIC PRODUCT (PACK)

PROGESTERONE (INJ) (1)

PROGESTERONE (VAG)

PROGESTERONE MICRONIZED (ORAL) (1)

PROLIA SOLN (INJ)

PROMETHAZINE W/ CODEINE (ORAL)

PROPECIA (ORAL)

PRO-STAT MAX (ORAL)

PRO-STAT RENAL CARE (ORAL)

EXCLUDED DRUGS

PRO-STAT SUGAR FREE (ORAL) PRO-STAT SUGAR FREE AWC (ADVANCED WOUND CARE) (ORAL) PRO-STAT SUGAR FREE AWC (ORAL)

PROSTIN VR (INJ) (2)

PROTEOLIN (ORAL) PSEUDOEPHEDRINE-ACETAMINOPHEN (ORAL) PSEUDOEPHEDRINE-GUAIFENESIN (ORAL)

PSEUDOEPHEDRINE-IBUPROFEN (ORAL) PSEUDOEPHEDRINE-NAPROXEN SODIUM (ORAL) QTERN (ORAL)

QUINOSONE KIT

RABIES IMMUNE GLOBULIN (HUMAN) (INJ)

RANITIDINE HCL (TABS/CAPS)

REBLOZYL (INJ)

RELTONE (ORAL)

REMICADE (I.V.)

RETISERT (IMPLANT)

RHEUMATE (ORAL)

RHO D IMMUNE GLOBULIN (HUMAN) (INJ)

RHOFADE CREAM (TOPICAL)

RIDUZONE (ORAL)

RITUXAN HYCELA SOLN (INJ)

ROSADAN KIT (TOPICAL)

Kaiser Permanente Commercial HMO Drug Exclusion List Listed are items that are excluded from prescription benefit coverage.

All of the excluded drug entities, strengths, formulations &/or package sizes may not be listed. The list is not all inclusive and is subject to change.

Office administered drugs and IV drugs are covered under the Medical benefit and excluded from being dispensed from retail pharmacy.

(1)(2)(3) Drug Category is excluded unless your plan has a buy-up for that benefit (1) Infertility Drug Category; (2) Sexual Dysfunction Drug Category; (3) Weight Loss Drug Category

KPCO Commercial HMO Drug Exclusion List Page 13 of 17

Revision date: November 2021

EXCLUDED DRUGS

RYLAZE SOLN

SCARCIN LIQUID (TOPICAL)

SCULPTRA (INJ)

SEGLUROMET (ORAL)

SENTRA AM (ORAL)

SENTRA PM (ORAL)

SEXUAL DYSFUNCTION DRUGS (ORAL/INJ) (2)

SIBUTRAMINE HCL MONOHYDRATE (ORAL) (3)

SIGNIFOR LAR (INJ)

SIKLOS 1000 MG (ORAL)

SILA III (PACK)

SILALITE PAK (TOPICAL)

SILAZONE THP (TOPICAL)

SILDENAFIL CITRATE (ORAL) (2) SILVER CARBOXYMETHYLCELLULOSE SOD/BANDAGES & RELATED PRODUCTS (SUPPLIES) SINUVA IMPLANT

SMARTRX GABA THPK (PACK)

SMARTRX GABA-V THPK (PACK)

SODIUM FLUORIDE (DENTAL) SODIUM FLUORIDE-POTASSIUM NITRATE (DENTAL) SOLARAVIX (PACK)

SOLESTA GEL (IMPLANT)

SOLIQUA (INJ)

EXCLUDED DRUGS

SOLOX GEL (TOPICAL) SPACER/AEROSOL HOLDING CHAMBERS (DEVICE) SPRAVATO (NASAL)

STAXYN (ORAL) (2)

STEGLUJAN (ORAL)

STENDRA (ORAL) (2)

SUBLOCADE SOSY INJ

SUMATRIPTAN-NAPROXEN SODIUM (ORAL)

SUPER SOLUBLE DUOCAL (ORAL)

SUPPRELIN LA/VANTAS (KIT)

SYNAGIS (INJ)

SYNJARDY IR & XR (ORAL)

SYNVISC (INJ)

TASOPROL KIT

TAZAROTENE (FACIAL WRINKLES) (TOPICAL)

TEARS AGAIN HYDRATE (ORAL) TERBINAFINE-HYDROXYPROPYL CHITOSAN (KIT) TESTOSTERONE CYPIONATE (KIT)

TESTOSTERONE PELLETS (IMPLANT)

THERAMINE (ORAL)

THROAT LOZENGES (ORAL)

THYROTROPIN ALFA (INJ)

TICALAST

TICASPRAY (NASAL)

Kaiser Permanente Commercial HMO Drug Exclusion List Listed are items that are excluded from prescription benefit coverage.

All of the excluded drug entities, strengths, formulations &/or package sizes may not be listed. The list is not all inclusive and is subject to change.

Office administered drugs and IV drugs are covered under the Medical benefit and excluded from being dispensed from retail pharmacy.

(1)(2)(3) Drug Category is excluded unless your plan has a buy-up for that benefit (1) Infertility Drug Category; (2) Sexual Dysfunction Drug Category; (3) Weight Loss Drug Category

KPCO Commercial HMO Drug Exclusion List Page 14 of 17

Revision date: November 2021

EXCLUDED DRUGS

TIZANIDINE & LINIMENT (PACK)

TOCILIZUMAB (INJ)

TORADOL (INJ)

TOVET KIT

TOXICOLOGY SALIVA COLLECTION (KIT)

TOXOIDS (INJ)

TOZAL (ORAL)

TRELSTAR MIXJECT SUSR (INJ)

TREPADONE (ORAL)

TRETINOIN (FACIAL WRINKLES) (TOPICAL) TRETINOIN W/ CLEANSER & MOISTURIZER (KIT) TRETIN-X (KIT)

TREXIMET (ORAL)

TRIAMCINOLONE ACETONIDE (NASAL) TRIAMCINOLONE ACETONIDE-DIMETHICONE-SILICONE (KIT) TRIAMCINOLONE ACETONIDE-SILICONE (PACK) TRIGLIDE (ORAL)

TRIJARDY XR (ORAL)

TRILOCICLO KIT (TOPICAL)

TRI-LUMA (TOPICAL)

TRIPTODUR (INJ)

TRIXYLITRAL PACK TRYPSIN, BALSAM PERU AND CASTOR OIL (TOPICAL)

EXCLUDED DRUGS

UREA (TOPICAL)

UROFOLLITROPIN PURIFIED (INJ) (1)

UTI-STAT (ORAL)

VACCINE/TOXOID COMBO (INJ)

VACCINES (INJ)

VANIQA (TOPICAL)

VAROPHEN KIT

VASCAZEN (ORAL)

VASCULERA (ORAL)

VASOLEX (TOPICAL)

VAYACOG (ORAL)

VAYARIN (ORAL)

VAYAROL (ORAL)

VENLAFAXINE HCL ER (TAB)

VERAMYST SUSP (NASAL)

VIAGRA (ORAL) (2)

VIMOVO (ORAL)

VITRASERT (IMPLANT)

VIVLODEX (ORAL)

VP-GSTN (ORAL)

VP-PRECIP (ORAL)

VSL#3 (ORAL)

WHYTEDERM (KIT)

WOUND DRESSINGS (SUPPLIES)

Kaiser Permanente Commercial HMO Drug Exclusion List Listed are items that are excluded from prescription benefit coverage.

All of the excluded drug entities, strengths, formulations &/or package sizes may not be listed. The list is not all inclusive and is subject to change.

Office administered drugs and IV drugs are covered under the Medical benefit and excluded from being dispensed from retail pharmacy.

(1)(2)(3) Drug Category is excluded unless your plan has a buy-up for that benefit (1) Infertility Drug Category; (2) Sexual Dysfunction Drug Category; (3) Weight Loss Drug Category

KPCO Commercial HMO Drug Exclusion List Page 15 of 17

Revision date: November 2021

EXCLUDED DRUGS

WPR PLUS WOUND HEALING SYSTEM

ZEYOCAINE KIT

XARACOLL IMPL

XGEVA (INJ)

XIGDUO XR (ORAL)

XOLAIR (INJ)

XULTOPHY (INJ)

ZOLPAK KIT

XRYLIX (TOPICAL)

EXCLUDED DRUGS

XYZAL (ORAL)

YOSPRALA (ORAL)

YUTIQ (IMPLANT)

ZILACAINE PATCH

ZILRETTA (INJ)

ZINC CITRATE-PHYTASE (ORAL)

ZOLGENSMA (I.V.)

ZOLADEX (IMPLANT)

60577108_ACA_1557_MarCom_CO_2017_Taglines

NONDISCRIMINATION NOTICE

Kaiser Foundation Health Plan of Colorado (Kaiser Health Plan) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Kaiser Health Plan does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. We also:

• Provide no cost aids and services to people with disabilities to communicate effectively with us, such as: • Qualified sign language interpreters • Written information in other formats, such as large print, audio, and

accessible electronic formats

• Provide no cost language services to people whose primary language is not English, such as: • Qualified interpreters • Information written in other languages

If you need these services, call 1-800-632-9700 (TTY: 711).

If you believe that Kaiser Health Plan has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance by mail at: Customer Experience Department, Attn: Kaiser Permanente Civil Rights Coordinator, 2500 South Havana, Aurora, CO 80014, or by phone at Member Services: 1-800-632-9700. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, 1-800-368-1019, 1-800-537-7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

___________________________________________________________________

HELP IN YOUR LANGUAGE ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call 1-800-632-9700 (TTY: 711).

አማርኛ (Amharic) ማስታወሻ: የሚናገሩት ቋንቋ ኣማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች፣ በነጻ ሊያግዝዎት ተዘጋጀተዋል፡ ወደ ሚከተለው ቁጥር ይደውሉ 1-800-632-9700 (TTY: 711).

إذا كنت تتحدث العربیة، فإن خدمات المساعدة اللغویة تتوافر لك بالمجان. ) ملحوظة:Arabicالعربیة ( (. TTY :711) 1- 800- 632-9700اتصل برقم

Ɓǎ sɔ́ɔ̀ Wùɖù (Bassa) Dè ɖɛ nìà kɛ dyéɖé gbo: Ɔ jǔ ké m̀ Ɓàsɔ́ɔ̀-wùɖù-po-nyɔ̀ jǔ ní, nìí, à wuɖu kà kò ɖò po-poɔ̀ ɓɛ́ìn m̀ gbo kpáa. Ɖá 1-800-632-9700 (TTY: 711)

60577108_ACA_1557_MarCom_CO_2017_Taglines

中文 (Chinese) 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電

1-800-632-9700（TTY：711).

ت زبانی بصورت رایگان برای شما فراھم می اگر بھ زبان فارسی گفتگو می کنید، تسھیلا توجھ: (Farsi)فارسی ) تماس بگیرید. TTY) 711: 1-800-632-9700باشد. با

Français (French) ATTENTION: Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 1-800-632-9700 (TTY: 711).

Deutsch (German) ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-800-632-9700 (TTY: 711).

Igbo (Igbo) NRỤBAMA: Ọ bụrụ na ị na asụ Igbo, ọrụ enyemaka asụsụ, n’efu, dịịrị gị. Kpọọ 1-800-632-9700 (TTY: 711).

日本語 (Japanese) 注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。1-800-632-9700（TTY: 711）まで、お電話にてご連絡ください。

한국어 (Korean) 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-800-632-9700 (TTY: 711) 번으로 전화해 주십시오.

Naabeehó (Navajo) Díí baa akó nínízin: Díí saad bee yáníłti’go Diné Bizaad, saad bee áká’ánída’áwo’dé̖ é̖ ’, t’áá jiik’eh, éí ná hóló ̖, koji̖’ hódíílnih 1-800-632-9700 (TTY: 711).

नेपाली (Nepali) �ान िदनुहोस:◌् तपाइ�ले नेपाली बोल्नु�न्छ भने तपाइ�को नन�त भाषा सहायता सेवाह� निनः शु� �पमा उपल� छ । 1-800-632-9700 )TTY: 711( फोन गनहोस ◌्।

Afaan Oromoo (Oromo) XIYYEEFFANNAA: Afaan dubbattu Oroomiffa, tajaajila gargaarsa afaanii, kanfaltiidhaan ala, ni argama. Bilbilaa 1-800-632-9700 (TTY: 711).

Pусский (Russian) ВНИМАНИЕ: eсли вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-800-632-9700 (TTY: 711).

Español (Spanish) ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-632-9700 (TTY: 711).

Tagalog (Tagalog) PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-800-632-9700 (TTY: 711).

Tiếng Việt (Vietnamese) CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-800-632-9700 (TTY: 711).

Yorùbá (Yoruba) AKIYESI: Ti o ba nso ede Yoruba ofe ni iranlowo lori ede wa fun yin o. E pe ero ibanisoro yi 1-800-632-9700 (TTY: 711).